ABSTRACT
BACKGROUND: Microvascular reconstruction after oncologic resection with curative intent in recurrent or second primary cancer cases is challenging not only because of the complexity of the defect but also due to difficulty in finding suitable donor vessels in the neck that has already been subjected to surgery and subsequent adjuvant treatment. In our present study, we evaluated the success of free flaps, reexplorations, and factors associated with reexploration and with flap failures in previously operated and/or radiated neck. METHODS: In this retrospective study, we analyzed patients who underwent microvascular reconstruction from January 2016 to December 2018 in patients with previous surgery and/or radiation, considered as "already treated neck" (ATN). These cases were reviewed to analyze variables that included age, sex, indication for surgery (recurrence, second primary, osteoradionecrosis, and secondary reconstruction), duration since previous surgery or radiation, free flap done, donor vessels used, the need to go to the contralateral neck or outside the neck, need for vein grafts, flap reexploration rate, flap survival rate, and hospital stay of the patients. We also tried to identify factors that predisposed for a reexploration after performing reconstruction with a free flap in ATN. RESULTS: Of 1522 free flaps done, 371 patients were included in the study. Flap success rate was 90.8% in ATN, which was comparable to naive neck (94%; P = 0.108). The reexploration rate in ATN (16.2%) was significantly higher (P = 0.0003) than in naive neck (9.8%). The previous treatment (neck dissection) received [P = 0.001; odds ratio, 13.7 (1.87-101.6)] was the most significant predisposing factor, and patients undergoing osteocutaneous flaps were more prone to undergo reexplorations (P = 0.05). Side of anastomosis, vessel used for anastomosis, comorbidities, and time since previous treatment did not affect the reexploration rate significantly. CONCLUSIONS: Microvascular reconstruction can be safely performed in ATN with good success rates, and it should not be a deterrent in whom free flap is required to achieve best functional outcome. However, it may be associated with increase in reexploration rates in the postoperative period. Patients having undergone a previous neck dissection are at more risk of undergoing this reexploration in comparison with radiotherapy (RT)/chemotherapy and radiotherapy (CTRT) alone.
Subject(s)
Free Tissue Flaps , Head and Neck Neoplasms , Plastic Surgery Procedures , Head and Neck Neoplasms/radiotherapy , Head and Neck Neoplasms/surgery , Humans , Neck , Neck Dissection , Retrospective StudiesABSTRACT
A 17-year-old girl with large malignant phyllodes tumor of left breast underwent a radical mastectomy with large skin excision resulting in defect of 20 cm × 18 cm. Postoperative radiation therapy necessitated robust cover with flap. The challenge was compounded by her body habitus. Both abdomen and back were deficient as donor sites and a single-island anterolateral thigh (ALT) flap would need skin grafts, volume deficit withstanding. We harvested chimeric ALT plus tensor fascia lata (TFL) perforator free flap sparing all muscles and nerves. Microvascular anastomoses were done to the second internal mammary artery (IMA) perforator artery and vein. The donor site was closed primarily. The TFL flap territory recruited almost three times the volume of ALT territory and allowed us to create a matching breast mound in addition to covering the defect. She tolerated 40 Gy radiation well and doesn't desire further augmentation. Consistency of ALT and TFL perforators makes this a replicable procedure.
ABSTRACT
Background Setting the angle of tip rotation is of utmost importance in achieving satisfactory results in rhinoplasty. Conventionally the upward rotation of the tip requires shortening of the septum by caudal resection and shortening of the lateral walls by cephalic trim of the alar cartilages. The results are usually assessed subjectively. We describe the use of objective parameters to ensure accuracy of nasal tip rotation in patients operated with "cock-up" alar cartilage flaps, a modification of the cephalic trim. Methods Fifteen patients with a long nose having adequate width of lateral crura, desiring a shorter nose with upward tip rotation, were included in the study. Values of preoperative and desired nasolabial angle (from morphed images), and the derived columellar-labial angle were documented. Nasal tip rotation was set to the derived angle and maintained using cock-up alar cartilage flaps. The outcome was evaluated by digital measurements of the nasolabial angle and patients' feedback by Rhinoplasty Outcome Evaluation (ROE) score. Results Satisfactory tip rotation and an aesthetic supratip area could be achieved. The difference in preoperative and postoperative nasolabial angles was statistically significant (p value < 0.0001). The difference in desired and the obtained nasolabial angle was not significant (p value 0.085). The results were maintained on subsequent follow-up. Conclusion Application of angles in practice and use of K-wire template helps us achieve accurate and consistent results. Cock-up flap is an effective technique-to obtain an open nasolabial angle and a desirable supratip region by making use of tissues otherwise discarded.
ABSTRACT
Herniation of colonic mucosa through the circular muscles at the point of penetration of blood vessels results in diverticuli formation. It is seen most commonly in the large bowel in sigmoid colon. Common complications of diverticular disease are inflammation and bleeding per rectum and rarely fistula formation which are seen mostly in elderly patients. A case of colovesical fistula with diverticulitis in young male aged 30 years is reported.
